Special features

Acute coronary syndromes — assessment and interventions

By Andrew Worrall, MBChB, MRCP, and Gary Fletcher, BSc, MRPharmS

Acute coronary syndromes account for a large proportion of coronary heart disease cases in the UK. This article describes the causes and symptoms, interventional management, and lists the risk factors that must be addressed to prevent a recurrence

This article as a PDF (200K)

Andrew Worrall is research fellow in cardiology, Royal Wolverhampton Hospitals NHS Trust

Gary Fletcher is principal pharmacist, cardiothoracic services, Royal Wolverhampton Hospitals NHS Trust

Sovereign, ISM/SPL

Metal stent

Metal stents are used to maintain patency of coronary vessels

SUMMARY

The acute coronary syndromes (ACSs) are a spectrum of common conditions which may be thought of as a subset of coronary heart disease (CHD). They tend to present suddenly or over a short period and cause considerable mortality and morbidity.

There is currently a global epidemic of CHD, and the total disease burden in western societies is one of the highest for any disease. ACS accounts for a large proportion of this burden.

Research over the past three decades has led to a greater understanding of the underlying mechanisms of ACS, leading to a more accurate clinical classification and new techniques for treatment, which have had a major impact on survival rates.

An understanding of ACS and the current treatment is therefore essential for anyone involved in the care of these patients, from primary to tertiary care.

Risk factors for developing coronary heart disease (CHD)

Non-modifiable risk factors

• Increased age Over 83 per cent of people who die of CHD are aged 65 or older.

• Male sex Men have a greater risk than premenopausal women. After the menopause, a woman’s risk increases dramatically, although it never equals that of a man of the same age.

• Family history Risk is doubled in those with a first-degree relative (eg, father or brother) who develops premature (age <60 years) CHD. Additional first and, to a lesser extent, second degree relatives will further increase this risk.

• Race Certain populations in the UK are at increased risk. Some of this is due to differences in the prevalence of type II diabetes mellitus. For example, in black Caribbean and Indian males the prevalence rates are 9.5 per cent and 9.2 per cent, respectively, compared with 3.8 per cent in the general population.

Modifiable risk factors

• Tobacco smoke Tobacco smoke was one of the first risk factors identified by the Framingham Heart Study in 1960. Smokers’ risk of developing CHD is two to four times that of non-smokers. Cigarette smoking is a powerful independent risk factor for sudden cardiac death in patients with CHD — smokers have about twice the risk of non-smokers.

• High blood cholesterol A higher blood cholesterol level increases the risk of CHD. Increased low-density lipoprotein raises the risk further, while high-density lipoprotein may be protective.

• High blood pressure High blood pressure increases the risk of CHD. There has been debate regarding the importance of systolic and diastolic readings, but data from the offspring of the Framingham cohort suggest that the greater the difference between systolic and diastolic readings, the greater the risk.

• Physical inactivity An inactive lifestyle is a risk factor for CHD. Regular, moderate-to-vigorous physical activity helps reduce the risk.

• Obesity People who have excess body fat are more likely to develop CHD even if they have no other risk factors. This is especially true of those with a high hip-to-waist ratio.

• Diabetes mellitus Diabetes greatly increases CHD risk. The risks are even greater if blood glucose is not well controlled. This can be measured using levels of glycosylated haemoglobin (HbA_1c). About three-quarters of people with diabetes die of cardiovascular disease.

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